Combating Racism and Placeism in Medicine

the medical profession

may be doing harm to patients and

communities

many years ago as a first year medical

student i took an oath

like thousands of physicians before me

and thousands of physicians after me

that i would first do no harm to the

patients

and the communities that i serve and

since then i have committed my career

for taking care of patients and

underserved communities

just like this one on the near east side

of columbus ohio

but over time i’ve seen that the medical

profession has broken that social

contract

with the communities that we serve

because of racism

and placism now this is going to be best

illustrated if i walk you through the

lives of two of my dear friends

so first let me tell you who they are

many years ago

as a young aspiring physician new to

practice i started my career off in

connecticut

where i had the good fortune of meeting

two wonderful women

who’d become lifelong friends and

honestly like family

and it is through their lenses that i

will walk you through the impact of

racism and placism in medicine

so first i want you to meet wendy

wendy’s a black woman

i met wendy as a middle-aged mother

hard-working woman working so hard to

provide for her kids

through my relationship with wendy i’ve

learned so much about tenacity

grit and honesty i also want you to meet

sarah

sarah’s a white woman i also met her as

a middle-aged woman

a mother hard-working did so much to

provide for her family as well

and through my friendship with sarah

i’ve learned so much about allyship

and loyalty now when i met wendy and

sarah

they lived about six miles apart in

central connecticut

sarah and the wealthier suburbs outside

of west hartford

and wendy in the inner city outside of

east hartford

although they only live six miles apart

their potential interactions with the

healthcare system could not have been

any more different

because of racism and placism

so let’s talk about what those mean and

what those look like in medicine

racism and medicine means that wendy as

a black woman

would be much less likely to have

positive interactions with the health

care system

much less likely to be taken seriously

by doctors and much less likely to have

state of the art healthcare wherever she

lived

because in medical school we are taught

that black patients have a higher

threshold for pain

if wendy came to my office with

presenting with pain

as a black woman she would be

significantly less likely to have that

pain addressed

similarly if wendy as a black woman

presented to the emergency department

with crushing chest pain

she would be 50 less likely to receive

any life-saving intervention

for a heart attack now in medicine and

in nursing we’re often taught to

discount and discredit

the symptoms of black women so if wendy

as a black woman

went through her pregnancy she would be

three to four times as likely to die in

that pregnancy or in the childbirth

than sarah would as a white woman

similarly if wendy gave birth

to a baby she would be twice as likely

to bury

her baby before the age of one than

sarah would as a white woman

and if wendy gave birth to a black baby

and that baby was taken care of by a

white physician

that baby would have an increased risk

of dying in that first year

racism and medicine also means that

although wendy as a black woman would be

much less likely to be diagnosed

with breast cancer or colon cancer if

she were diagnosed

she would be diagnosed with much more

advanced disease

later stage disease and have a 50

percent higher mortality than sarah as a

white woman

and so it’s not really the phenotype of

race it’s the structures of racism

that would lead wendy to toxic

accumulation of stress

that would lead her to earlier heart

disease than sarah so racism is taking

its toll

in medicine now the other issue

is placism and by placism i mean the

ignorance of

a person’s place where they live their

zip code on their health

we know that 80 of a person’s health

status is determined

by social determinants of health not

their interaction with me as their

doctor

the conditions where they live work play

school

housing economic security

jobs safety violence but chances are

your doctor has looked at you and made a

decision on how they will care for you

based on your race

but they have never paid attention to

your place

or your zip code so this is this shows

up in significant health disparities in

life expectancy

if you look at the state of ohio in

green you’ll see

the wealthier parts of the state people

have a life expectancy

into their late 80s almost into their

90s

not too far from some of these same

places in red you see that people have a

life

expectancy in their 60s so there can be

a 29 year difference

in your life expectancy based on where

you live

now if we zoom in on where i am right

now in central ohio

the life expectancy challenges are the

same you can see places that are not

that far away

have over 27 years of a difference in

life expectancy between the poor and the

wealthier

zip codes where i’m standing right now

on the near east side of columbus ohio

a mile away in a wealthier suburb of

bexley

people are expected to live 18 years

longer than the people in the community

that i’m standing in

chances are no matter where you are in

the united states these same health

disparities exist

these same problems based on your place

exist

so back to wendy and sarah when i met

wendy and sarah

they lived about six miles apart

but that meant that sarah was expected

to live to the age of 84.

and wendy to the age of 68 a 16-year

difference based on six miles

so you may wonder what if we just moved

wendy over to where sarah lived

would that change unfortunately because

racism would follow her wendy’s life

expectancy would not change

it would be as if wendy lived in the

same place

for her whole life and that is because

racism is the father of placism

places him as the derivative of racism

structural housing discrimination

redlining and many other structural

factors have led to the reasons why

people in certain communities

have lower life expectancies so how then

can i have

lifelong friendships with wendy and

sarah i want us all to live and have our

relationships until we’re in our 80s

this is where i believe that we can make

a difference through changes in

education

and leveraging technology so with

education

we need to dismantle and deconstruct

racist oppressive prejudicial biased

education that we provide to medical

students nursing students and other

health professions students

the same mythology and stereotypes that

were used to justify slavery

are still used in medicine today we need

to dismantle and deconstruct

that sort of education and instead

replace it with anti-racist

anti-oppressive scientifically focused

stereotype free

and informed care that allows us to give

equitable care to our patients

but what do we do then if we change the

educational system we know educational

reform takes a long time

what do we do about the thousands and

thousands of physicians

physicians like me who are not going

back to school anytime soon

but they have been unfortunately

indoctrinated with these awful

stereotypes and beliefs about their

patients

this is where i believe the second

solution can help us technology can help

us be anti-racist

and anti-places so what might this look

like

chances are if you go to a doctor’s

office they are using an electronic

medical record where they’re collecting

so much information about you

and i believe that we can use clinical

decision algorithms

that will allow us to be anti-racist and

anti-places at the point of taking care

of you

because most doctors have looked at your

race but they have not asked about your

place

so what would this look like in real

life let’s say a patient molly came to

my office

and in the course of care which is

customary my medical assistant before i

see her would collect her height her

weight

her blood pressure and ask her about her

pain on a scale of zero to ten

with zero being little pain and ten

being her worst pain

what if molly said she had a seven out

of ten pain but as often happens to

black patients i didn’t pay attention to

it what if the technology could call

that pain to my attention

and stop me before i could do anything

else in that electronic health record

and say

studies tell us that black women are

much less likely to have their pain

addressed are you sure you do not want

to address molly’s pain

i could say yes i’m sure i do not want

to address her pain

i want to be racist or i could go back

and i could do something different

similarly if i was not managing her high

blood pressure

with the top of the line agents we know

that black patients often get the third

of the fourth line agent for their

hypertension

what if the technology stopped me here

too and forced me to be anti-racist

and reminded me that african-american

patients are much less likely to get

prescribed first-sign agents

are you sure you do not want to change

molly’s medication i could say yes

i’m sure i want to continue to be racist

or i could go back and do something

different

same thing could apply to colon cancer

screening if i did not screen my patient

as often happens

to black patients the system could ask

me it could force that into my

consciousness

it could force me to do no harm

what can we do about placism so chances

are we have not paid attention to your

zip code nor would we know what to do

with it if we saw it

so what if we use community mapping

tools and a lot of the geospatial

imaging that we have to tell us about

social determinants of health

not only your risk based on your zip

code but also what to do about it

what if the technology called out my

patient’s zip code and told me that she

lived in this zip code where she’s

likely to die early

from heart disease will you discuss

heart health and disease prevention with

your patient

i could say no i want to continue to be

places or i could go back

and do something different i believe we

can do this

i believe we can turn the tide and renew

that contract with medicine

but it’s going to take patients

institutions and doctors to all play

their part

so patience be empowered to ask more

from your doctors

you have a right to full health ask us

to address your pain

ask us what screenings you should be

having based on your age or your gender

ask us if we were really on the first

line medications for your condition

but institutions you also have a role

you need to retrain

your doctors your nurses your health

professionals deconstruct and

reconstruct that educational model that

you have

teach your physicians your nurses your

health professionals to see patients as

whole people

teach them to be humble culturally

empathetic

and to see their patients as their own

and finally

doctors my peers my colleagues

we took an oath we promised our patients

and our society that we would take care

of them that we would do no harm honor

your oath

and give patients the love and the care

that they need

and together we can give life love

hope and healing to the communities that

we serve

and together we can do no harm

thank you